computer-based cognitive training via a multifaceted€¦ · the university of sydney healthy brain...

The University of Sydney

Computer-based cognitive

training via a multifaceted

‘Healthy Brain Ageing’

program

Dr Loren Mowszowski

Healthy Brain Ageing Program

Brain and Mind Centre & School of Psychology


[email protected]


Healthy Brain Ageing Program: background

– Multi-faceted clinical research program,

est. 2007

– Focus on modifiable risk factors and

interventions for cognitive decline and

dementia

– Multi-disciplinary clinical and research

team

– Participants: >50y, recent onset cognitive

or mood change

– GP/Specialist referral required

Cognitive decline

Depression

Sleep

Cardio-vascular Disease

E-health

Intervention

Neuro-

imaging


Healthy Brain Ageing Clinic: assessment and intervention

Clinical and Biomarker assessment (modifiable risk factors for cognitive decline) (free of charge to patient)

1. Psychology / Psychiatry

2. Neuropsychology

3. Neurology / Geriatrics

Additional (optional) testing:

Neuroimaging (MRI, HD-EEG)

Actigraphy watch (2 week recording of sleep and circadian rhythms)

Overnight sleep study (PSG)

Blood work

• Feedback to participant and reports to referring physician

• Mechanism for recruitment into intervention trials

– Cognition

– Physical exercise

– Sleep (OSA; sleep hygiene)

– Oxytocin

– Art therapy

8%

19%

62%

11% Healthy

SMC

MCI

Dementia


Acknowledgements

Prof Sharon Naismith (head,

Healthy Brain Ageing Program)

Dr Keri Diamond (Clinical

Neuropsychologist)

Healthy Brain Ageing team

Our research participants

Contact details:

[email protected]

HBA Clinic: 9114 4002

[email protected]


Rationale for our Cognitive Training research: who, when and how

1) 2)

Multi-faceted approaches may be

optimal (Naismith et al., 2009; Rebok et

al., 2007)

• Strategy-training

• Computer exercises

• Psychoeducation

• Psychological therapy

• Physical exercise

Enables us to target difficulties

from multiple angles


Healthy Brain Ageing Cognitive Training & Psychoeducation Program

Non-randomized pilot, followed by RCTs

7-week course, twice-weekly sessions

One hour of psychoeducation and/or cognitive strategy

training and practice

Tea break (social engagement)

One hour of computer-based exercises (NEAR model)

Waitlist control condition (offered program after

completing follow-up Ax)

*Neuropsychological Educational Approach to Remediation; Medalia et al., 2008)


1) Psychoeducation:

Session Topic Speaker

1 The Brain, cognition and ageing Clinical Neuropsychologist

2 Attention: strategies Clinical Neuropsychologist

3 Memory: Encoding strategies Clinical Neuropsychologist

4 Memory: Storage problems Clinical Neuropsychologist

5 Memory: Retrieval strategies Clinical Neuropsychologist

6 Executive functions: strategies Clinical Neuropsychologist

7 Vascular risk factors Old Age Psychiatrist

8 Diet Nutritionist

9 Exercise Exercise Physiologist

10 Depression: pharmacological treatments Old Age Psychiatrist

11 Depression: CBT and behavioural treatments Clinical Psychologist

12 Anxiety and stress management Clinical Psychologist

13 Sleep Chronobiologist

14 Internet tools (finances, emails, current affairs) Clinical Neuropsychologist


Psychoeducation: snapshots


2) Strategy-based cognitive training:

External memory strategies

– Using a diary

– Making lists or notes

– Post-it notes

– Alarm clocks

– Keeping things in consistent places

Internal memory strategies

– Repetition / rehearsal

– Chunking

– Semantic clustering

– Visual imagery

– Mnemonics

– Aim to ‘take the strain off the brain’

– Maximising cognitive processing

– Clinicians provide guided practice internalization

– Emphasizing ‘real world’ application generalization


Find the face…


Visual scanning in everyday life


3) Computer-based cognitive training:

• Computer-based training

• Relies on clinician facilitation & guidance

• Intrinsic motivation – graded difficulty, positive reinforcement

• Individualized for cognitive strengths and weaknesses (based on formal Ax)

• Evidence-based – several RCTs in schizophrenia, ageing

Neuropsychological Educational Approach to Remediation (Medalia et al., 2008)


3) Computer-based cognitive training:

“Drill and practice” approach targeting various

cognitive domains (individualised therapy plan)

Platform for practicing strategies

Purpose-built training lab with computers and

specialised software

Software selection based on task analysis

Examples:

CogPack, Brain Trainer, Posit Science

Mahjongg, I Spy, Sudoku, Zoombinis


Treatment progress and feedback

Participant feedback & reflection Session-by-session therapy record


Results: HBA-CT in late-life depression, (n=41; mean age = 64.8y)

– Pilot trial of HBA-CT program;

first trial of CT in late-life

depression

– Significant improvements in

verbal memory and visual

learning

– Improved knowledge re.

modifiable risk factors

– Limitation: not an RCT

Naismith et al., 2011, Am J Geriatric Psychiatry;

Norrie et al., 2010, Int. Psychogeriatrics


– Treatment-related improvement in verbal memory (p=0.029) and sleep quality (p=0.022) remained significant after controlling for change in mood

– Improvement in memory may be partly mediated by concurrent improvements in sleep (p=0.07)

Results: RCT of HBA-CT in ‘at risk’ older adults (n = 64; mean age = 66.5y)

Memory retention

p=0.02; r=0.3 (medium)

Self-reported depressive symptoms

p=0.01; r=0.3 (medium) Subjective sleep quality

p=0.01; r=0.3 (medium)

Diamond et al., 2015, Journal of Alz Dis


Results: individual differences

– 35 ‘treatment’ participants divided into responders vs non-responders

Characteristic Responders

(n=12)

Non-

responders

(n=23)

χ2 / t P value

Lifetime history of depression (yes) 11 (91.6%) 11 (47.8%) 6.49 .011*

MCI (proportion amnestic) 3 (25%) 17 (73.9%) 7.70 .006*

MMSE (total raw, /30) 28.75 (1.28) 27.00 (2.17) 2.55 .015*

WHODAS

understanding/communicating (total

raw / 30)

7.75 (4.63) 4.73 (2.92) 2.36 .025*

WHODAS getting along with others

(total raw / 25)

5.08 (3.14) 2.43 (2.33) 2.83 .008*

– Responders more likely to have a history of depression; have non-amnestic MCI, have higher self-rated disability at baseline.

– No difference in gender, age, education, depressive episodes/symptoms, medical burden, no. sessions completed, IQ.

Diamond et al., In preparation


Results: Enhanced neurophysiological response in treatment group

(‘at risk’ subsample, n = 40, mean age = 66.4y)

• Post-intervention increase in frontal and central Mismatch Negativity ERP amplitude

• Suggestive of enhanced ‘pre-attentive’ processing

Mowszowski et al., 2014; Journal of Alz Dis


• Trial 1: N = 50, improved verbal learning and memory in patients with Parkinson’s disease

• First in the world to demonstrate this effect

Results: patients with Parkinson’s disease

• Trial 2: N = 65, program adapted to target executive dysfunction underpinning Freezing of Gait

• Reduced freezing of gait, improved processing speed, daytime sleepiness

Naismith, Mowszowski et al., 2013, Movement Dis

Walton, Mowszowski et al., 2018, npj Parkinson’s Dis


How are we implementing this program?

– Public health setting: – Psychogeriatric out-patients with late-life depression (St

Vincent’s Hospital, Sydney, Australia)

– Individualised approach; facilitated vs. independent completion – CogMax trial, structured interactive workbook (strategy

training and psychoeducation), collaborative goal setting

– Online adaptation – CogNet trial, structured interactive program (strategy

training and psychoeducation)

– Other clinical populations:

– Chronic Obstructive Pulmonary Disease (Dr Rebecca Disler, University of Melbourne)


Lessons learned?

– Challenges:

– Initially time and resource intensive (to establish)

– Structured program did not allow for individualized goal setting

– Occasionally, difficult to balance complexity/detail of psychoeducation across each group

– Program is well received by patients and referrers

– Excellent adherence and acceptability

– Qualitatively, patients become more engaged, build a ‘support network’

– Multifaceted approach has clear clinical benefits

– Maintained patient interest and motivation

– Enabled clinician guidance and promoted ‘real world’ application

– Structured approach easy to implement

– Easily adaptable once establish core materials (psychoeducation, computer task analyses etc.)

– Templates for therapy plans, record keeping, participant ratings

computer-based cognitive training via a multifaceted€¦ · the university of sydney healthy brain...

Documents